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With the foregoing extracts I shall now conclude, with the single remark that those who may object to the treatment of the cholera by calomel, on the ground that they do not understand the mode of its action, should with equal reason reject the use of quinine in intermittents, for of the mode by which that medicine acts nothing whatever is known. It is strictly an empirical remedy, yet it is nevertheless an invaluable one, and it is therefore ardently to be hoped that the testimony of so many unbiassed witnesses to the value of the treatment will not be thrown away, and that the profession of these kingdoms, in imitation of their brethren in the United States, will give it a fair trial, feeling assured, as I do, that having, like their American brethren, given it such trial, they will, like them, never desire to abandon it.-Lancet, Oct. 1, 1853, p. 321.

157.-Treatment by Large Doses of Calomel.

[Mr. F. W. RICHARDSON, of Woolwich, Surgeon to the Royal Kent Infirmary, in a letter to the editor of the 'Lancet,' observes:]-A person is affected with cholera because he has a specific poison in his blood, just as others are liable to measles, scarlet fever, small-pox, typhus, &c., because they have other poisonous matters in the circulating fluid. The materies morbi produces an altered condition of the blood, attended with great prostration of strength, vomiting and purging of a serous fluid, containing soluble salines, some albumen, epithelial scales, and perhaps fibrin, and the blood thus inspissated causes congestion of the Malpighian capillaries of the kidney, with suppression of the urine, which, together with the other retained secretions, still further damage the blood.

The treatment consists in eliminating from the blood the morbid materials which are interfering with its normal condition. "There are reasons for believing that mercury occasions in the blood that dissolution of certain materials which is preliminary to their excretion;"* and coincidently with this change, produces increased activity in the secreting functions of the liver, the kidneys, the glandulæ of the intestinal canal, &c. We must, therefore, trust to calomel in large doses, uncombined with any other drug, to restore the secretions, and cure the patient. I am now speaking of collapse. Give an emetic, composed of fifteen grains of sulphate of zinc, and fifteen grains of ipecacuanha, and repeat it in ten minutes. In about twenty minutes, place twenty or thirty grains of calomel on the tongue, and repeat from two to ten grains, or more, every ten, twenty, or thirty minutes, according to the severity of the symptoms. Support the vital powers by beef-tea injections, administered every half-hour or hour. Allay the thirst and vomiting by ice or a tea-spoonful of very cold water, given ad libitum. Cautiously avoid all stimulants, for they have been shown to create positive mischief, and most alarming symptoms during the reaction. When the dejections again contain bile, continue small doses of calomel for a short time, and then give twenty grains of rhubarb, thirty grains of sulphate of potash, in some peppermint-water, or a castor-oil draught. Afterwards prescribe liq. am. acet. every four hours, or some carbonate of soda and tartaric acid in a state of effervescence. Then restore the strength in the way previously mentioned.

The gentleman who has been most successful during the past in managing the cholera is Dr. Ayre, of Hull, who employs small doses of calomel, combined with a small quantity of opium. He remarks "I have had seventy-six cases, of which sixty have been returned cured, five are under treatment, four of them are out of danger, and ten have died." Facts thus clearly prove that the calomel plan is the only rational and successful one; but I differ, however, from Dr. Ayre in several respects. I think emetics ought to be given at the onset, for they restore warmth to the surface, relieve the congestion of the internal organs, and shorten the attack. Again, it is acknowledged how necessary it is to support the vital powers, and it is on this principle that brandy is used; but beef-tea is the remedy, and as it cannot be administered by the mouth, it must be by the rectum. When the calomel is employed in large doses, the patient recovers more quickly, and the mortality is not so great. All severe cases of collapse under my care have recovered in from twentyfour to forty-eight hours. Dr. Ayre says, "the average duration of the disease in those who recovered under his treatment has not been more than from four to five days." He also talks of "the greater or less occasion for the subsequent employ

• Mr. Simon, 'Lancet,' vol. ii. 1850, p. 198,

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ment of leeching and the antiphlogistic remedies." I have never seen any necessity for such remedies, except when opium, brandy, chalk, &c., have been given.

I will add a few words concerning the premonitory symptoms. In my experience painless diarrhoea is extremely rare. sometimes vomiting; foul and coated tongue; pain at the stomach; often cramps in The symptoms are purging, nausea, retching, the abdomen and legs; and frequently coldness of the extremities. I would seriously ask any sensible, reflective person, if " twenty grains of opiate confection, mixed with peppermint water, or weak brandy-and-water, and repeated every three or four hours, or oftener," is "plain advice," or ought to be administered under such circumstances? I have had many cases of this kind under my care lately, and they all invariably and instantly yielded to emetics, ten grains of calomel placed on the tongue, followed in an hour's time by a rhubarb draught, which can be repeated as often as may be deemed requisite. It must not be forgotten, that it is a specific poison, often combined with putrescent organic matters, received into the blood, which occasions all the symptoms, and the quicker they are metamorphosed and discharged from the system the better.

In the epidemic diarrhoea of infants, I have found grain doses of calomel, given every two or four hours, perfectly effectual in curing the complaint. In infantile cholera, I give emetics, two grains of calomel every ten minutes, and beef-tea injections, as often as necessary.-Lancet, Oct. 8, 1853, p. 353.

158.-Treatment by Calomel, Counter-irritation, Astringents, &c.

[Mr. C. A. CHAVASSE, of Smithwick, Birmingham, has had an extensive experience of this disease both at home and abroad. Speaking of the treatment, he observes:]-I have seen every plan tried,-counter-irritation, brandy and laudanum, brandy and capsicum, cold affusion, transfusion; Stevens' saline with soda, chloride of sodium, and chloride of potash; the Australian sulphuric plan, mustard emetics, salt emetics, calomel and opium, opium and astringents, acetate of lead inclusive, calomel in large doses of one drachm every hour, and small doses of one grain every quarter of an hour, and many others too numerous to mention; some certainly with partial success, but all infinitely inferior in efficacy to the plan I am about to recommend, and which I first saw put in practice in India on a very large scale.

I have seen many hundred cases treated successfully by it; and several times forty or fifty successively. The proportion of recoveries to deaths was, I believe, about eight of the former to one of the latter; and to show the great malignancy of the disease before it was adopted, nearly all the cases died, often in two or three hours. Without further preface, I earnestly recommend the following:

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Warm turpentine epithegms, or mustard-poultices applied to the abdomen frequently. Take of calomel, prepared chalk, of each ten grains-make a powder-to be taken every hour in treacle, with half an ounce of the following mixture:-Take of compound powder of chalk with opium, powdered acacia, white sugar, of each, two drachms; sesquicarbonate of ammonia, one drachm and a half; cajeput oil, twenty minims; tincture catechu, three drachms; camphor mixture, eight ounces: mix. The above to be given until the evacuations become feculent-generally from twelve, sixteen, or twenty doses-and then the following substituted until the purging be quite stopped. Take of acetate of lead, half a drachm; strong acetic acid, half a drachm; Battley's sedative solution of opium, fourteen minims to one drachm; oil of cinnamon, four minims; tincture of ginger, three drachins; infusion quassia, to eight ounces: mix. An ounce to be given every two hours. Afterwards, decoction of bark, with dilute sulphuric acid, may be given. It is of the greatest importance that the calomel be of the lightest description, and triturated for a long time with the chalk.

The strength of the patient must be supported by giving, alternately, strong beeftea spiced with pepper-corns and seasoned with salt, and arrow-root and milk with brandy and nutmeg between each dose of the medicine.

Cold water may be allowed ad libitum.

Flannel should be worn next the skin.—Lancet, Oct. 8, 1853, p. 355.

159.-Treatment by Sulphur.

[Mr. JOHN GROVE, of Wandsworth, believes the antidote and remedy against cholera to be sulphur. This belief, he says, has been tested by Mr. Blacklock in

India, Dr. Bird in America, himself in England, and by the peasantry in Scotland. He does not say it is an infallible remedy, but he believes it to be of equal value to quinine in ague, or mercury in syphilis. He says:]-The value of a remedy depends much on the manner in which it is administered. The plan I have adopted is the following:-A mixture of twenty grains of sulphur (the pure precipitated), twenty grains of sesquicarbonate of soda, two drachms of compound spirits of lavender, and water sufficient to make up six ounces: a fourth part of this is given every two or three hours in ordinary diarrhoea, and it very rarely fails to cure at once if hot fluids and vegetables are discarded from the diet. If the disease has advanced to vomiting, the dose is repeated every quarter of an hour until the medicine is retained on the stomach, which generally happens after the second or third dose; the intervals are then prolonged according to circumstances. The same rule is observed when the spasmodic form of the disease occurs, and with equally favourable results. When diarrhoea has preceded the treatment for some days, I have found it useful to add five minims of tincture of opium, or sometimes ten, to each dose of the sulphur mixture, in order that the sulphur may be retained and absorbed, upon which I believe success to depend.-Lancel, Sept. 3, 1853, p. 304.

160.-Treatment by Sulphuric Acid.

[Dr. H. W. FULLER, Assistant Physician to St. George's Hospital, observes that it was not until September, 1851, that he had an opportunity of testing the efficacy of the newly introduced remedy, sulphuric acid. He says:]-In that month, two most urgent cases of choleraic diarrhoea, attended by extreme collapse, violent and incessant cramp, pinched features, rice-stool evacuations, and matters resembling chicken broth rejected from the stomach, were admitted about the same time into St. George's Hospital. Had these cases occurred in the autumn of '49, they would have been designated cases of Asiatic cholera; they differed in no respect from genuine cholera, and were entitled cases of choleraic diarrhoea simply because cholera was not then prevalent as an epidemic. In both these instances I administered sulphuric acid with complete success; and as the action of the remedy could be attested by pupils and others, who witnessed the success of the treatment, I published in the Medical Times and Gazette' (January 10, 1852) a detailed account of the effects observed, together with the general result of my experience. It amounted to thisthat the dilute sulphuric acid of the pharmacopoeia, administered in half-drachm doses, repeated at short intervals, has a powerful and immediate influence over the disease. The vomiting and purging cease, and the cramps subside, sometimes after the second, more usually after the third or fourth, dose of the medicine. The attack may leave the patient weak, and usually does so, in proportion to its severity, and the length of time which has elapsed before the administration of the remedy is commenced; but, within three or four hours, the disease is arrested, and convalescence follows speedily. Indeed, in ordinary cases, the change is effected with such marvellous rapidity, that he who in the morning is utterly prostrate, in the evening experiences little ill effect from his fearful seizure.

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I had hoped that this circumstantial report, backed as it was by the result of my own experience, extending at that time to twenty-seven cases, and as it has since been by the concurrent testimony of several practitioners in different parts of the country, would have led to a recognition of the extreme value of this treatment in all instances of choleraic diarrhoea, if not of cholera; at all events it seemed but fair to presume that testimony so decided, in favour of a remedy so cheap, so harmless, so extremely simple, so uniformly successful, and producing its successful and striking results within so short a time of its administration, would at least have insured a trial of its virtues. But, unfortunately, the profession clings so rigidly to routine, that comparatively few have been induced to employ it, and thus its virtue as an anticholera specific remains almost unknown or disregarded. To give large and repeated doses of calomel, or opium, or cajeput oil, or chalk, or brandy, to employ saline injections into the veins, to wrap the patient in bran or mustard poultices, or to have recourse to one or all of the many expedients which are often resorted to in severe cases, has certainly a much more imposing effect, and is a proceeding more strictly "selon la règle," than the simple administration of sulphuric acid; yet, when it becomes known that the latter mode of treatment, albeit simple and unpresuming, effects its purpose perfectly, sometimes within ore hour, usually within two, and alXXVIII.-20.

ways, I believe, within four hours; whereas the former, even when successful (and that it is often unsuccessful the Registrar General's Reports sufficiently attest), requires many hours for the accomplishment of the same object, and leaves the patient in a state requiring as many days for recovery, it cannot be much longer a question as to which method of treatment shall be adopted. This is a matter in which, if the profession will not act, the public will certainly take the initiative. If once it becomes known that a halfpenny-worth of acid is more than sufficient to effect a curethat the acid, when properly diluted with water, is so harmless, that it is not unfrequently drunk as a lemonade during the hot weather in the south of Italy, and, throughout the Continental states, is served out in accordance with a police regulation, as a daily beverage to all persons engaged in the manufacture of white-lead, it will not be long before a bottle of the dilute sulphuric acid of the pharmacopoeia is duly installed in every housewife's medicine cupboard. The profession have yet tine to take the matter into their own hands; but, if they do not soon avail themselves of their privilege, the public will assuredly step in, and deprive them of the opportunity.

My own conviction is, that in sulphuric acid we have an antidote-a specificagainst choleraic diarrhoea, if not against the worst forms of cholera, as powerful, as energetic, and as certain in its effect, as is cinchona bark, or quina, against a paroxysm of ague. In bilious diarrhoea, and in certain chronic diarrhoeas, it is of little or no avail; and, in some, though in very few, according to my experience, it gives rise to pinching pain in the abdomen; but in epidemic diarrhoea, in acute autumnal diarrhoea, if I may so term it, and in more decided choleraic diarrhoea, I have known no single instance of its failure; indeed, the more choleraic the diarrhoea, the more speedily are its curative effects produced. This fact will appear of greater value when it is known that I have notes of its administration in above ninety such cases, many of which have occurred among my own patients at the hospital or elsewhere, and some in the practice of my friends.

With this, however, even more than with the other remedies, success depends upon the mode of administration. Given at intervals of three or four hours, it fails in exerting any curative influence in severe cases, and is seldom of much avail even in milder cases; and to insure its beneficial effects, it should be exhibited in full doses, repeated at much shorter intervals. When I first began to give it, I ordered two doses to be taken within the first hour, and a dose to be repeated every hour afterwards. But recent and more extended experience, together with the close and eager observation of its influence on my own person, has convinced me that, even in ordinary cases, twenty minutes form a sufficient interval between each dose. In severe cases, five or six doses may be given with advantage within the hour; and should any dose be rejected by the stomach, another should be administered at *Rarely, however, is any dose rejected except the first, and the rejection of that is by no means common. While loathing the sight of other liquids, the patient, after he has tasted the first dose of the medicine, very generally craves for its repetition, and drinks it with avidity.

once.

As the stomach is very irritable, and the acid taken in simple water is, under the circumstances, extremely palatable, I never mix it with syrup or other matters; and I strongly suspect the warm aromatic spices, with which some of my friends have flavoured it, are additions by no means agreeable to the patient. Unfortunately I have had some personal experience in this matter, and so strongly was my distaste to the medicine excited by such flavourings, that for the future, whenever I am the patient, I shall certainly put my veto upon them.

The effects produced by this remedy are very remarkable. Sometimes, after the second dose, more commonly after the third, and almost always after the fourth,

Mr. Buxton, of Great George-street, Westminster, to whom the profession is greatly indebted for having been the first to call attention to the anti-choleraic properties of sulphuric acid, recommends the administration of half-drachm doses every quarter of an hour in severe cases. If those gentlemen who make trial of the remedy so strongly recommended by Mr. Buxton would use it as they ought, in the manner and in the dose he directs, and administer it only in proper cases, we should seldom, if ever, hear of its failing to arrest the course of the disease. In every instance within my own knowledge in which it has failed in its efficacy, the blame has been chargeable upon those who have administered it, rather than upon any want of virtue in the remedy itself. They have either given it in insufficient doses, or else in cases of bilious diarrhoea, with foul breath and loaded bowels, which would have been benefited by a brisk purge of calomel and rhubarb.

dose of the medicine, the patient experiences a grateful sense of warmth at the epigastrium; heat returns to the extremities; the nausea and vomiting immediately cease, even if they have not been arrested already; the purging is stayed, the cramps subside, and the countenance re-assumes its natural appearance. Very generally, perspiration breaks out, and the patient goes to sleep, and awakes refreshed, though feeling somewhat weak. The other symptoms betoken a like amendment. The tongue, which before was dry and furred or shrivelled, becomes moist and but slightly coated; the evacuations from the bowels assume a healthy colour, and are accompanied by an unusual discharge of bile; and the pulse regains its normal steadiness.

Such being the case, it is unnecessary, in mild or ordinary instances, to have recourse to any further treatment. With due precaution as to over-exercise and fatigue, and strict attention to the amount and nature of the diet during the next few days, so as to allow the stomach to recover its wonted energy before its powers are again fully taxed, the patient usually recovers without let or hindrance. The bowels act regularly without the assistance of medicine, and the dejections are of a healthy colour and consistence. But in severe cases, if care be not taken to maintain the good effects already produced, a relapse may occur, or recovery may prove tardy. The patient, though no longer troubled with diarrhoea, may digest imperfectly, and suffer greatly from nausea. For some time after these severe attacks, the secretion of bile takes place irregularly, and the bowels become costive or irritable, and the motions dark-coloured and offensive. Hence it is sometimes expedient to follow the sulphuric acid by two or three grains of blue pill, or a grain of calomel, administered at bed-time for a few successive nights, taking care during the day to impart tone to the stomach by the exhibition of some light bitter infusion, combined with potash and ammonia, small doses of tincture of rhubarb, and, if necessary, a little chalk. By some such means as these, all unpleasant after symptoms are prevented, and the patient proceeds steadily to convalescence.

On several occasions, it has occurred to me to try whether the same effects might not be produced by continuing the administration of sulphuric acid at intervals of six or eight hours. But the result of the experiment has not been encouraging. In some few instances the patient has improved steadily, but occasionally he has experienced a relapse, and has generally been longer arriving at perfect health than under the plan already indicated. Hence, as soon as the urgent symptoms have been subdued-i.e., after the first few hours-I usually discontinue the acid, and, if necessary, have recourse to the treatment above recommended as most conducive to the maintenance of its good effects.

For some time after a severe attack, strict attention to the diet is of the utmost importance. The food should be light and nutritious, taken in smaller quantity than usual, and at regular intervals. As a general rule, everything which is "bilious" disagrees with the stomach; but perhaps nothing produces derangement more certainly than malt liquor. I have tried every kind of beer, both in bottle and on draught, on myself and my patients, and almost uniformly with bad results. Excellent as bitter ale proves as a stomachic under ordinary circumstances, it usually produces a strange commotion after one of these attacks. No beverage should be employed except water, accompanied by a due allowance of wine, or, if necessary, a little brandy. Fruit and vegetables should be altogether avoided.-Medical Times and Gazelle, Oct. 1, 1853, p. 344.

161.—Treatment by Bicarbonate of Soda and Opium, called " Maxwell's Remedy.” [DR. CAMERON, 37th Regiment, writing to the Medical Times and Gazette,' states that Dr. Maxwell, of the Madras Cavalry, used to prescribe a mixture of bicarbonate of soda and opium in cases of this kind. It obtained such a notoriety that it was termed "Maxwell's remedy." Dr. Cameron was led to use the form from the remarkable effects it produced in a case very nearly approaching to true cholera.]— The proportions are as follows:-A scruple of sesquicarbonate of soda, with three grains of opium, given in the form of bolus, and washed down with a second scruple of soda in a wineglassful of water as hot as the patient can bear to swallow it. This to be repeated in the evening, with two grains of opium if necessary, and afterwards in diminished doses if required. I have never found it necessary to give a second bolus when the first was retained, and sometimes have succeeded in stopping the

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